Soins maternels intensifs (Maternal Intensive Care) en Belgique - KCE

KCE Reports 94 Maternal Intensive Care in Belgium 61
5 THEORETICAL MODEL
5.1 INTRODUCTION
As already mentioned in the literature review, the most important obstacle within our
search for evidence was the terminology used, i.e. we were not able to find any
literature which mentioned or referred to the concept “maternal intermediate care”.
Concepts as “high-dependency care” and “obstetrical intermediate care” appeared to
be best comparable to the typical Belgian MIC-concept. The result of this systematic
literature review on maternal intermediate care (MIC, cf. supra) provided a very
diverse, but limited amount of scientific literature.
A reasonable amount of articles/studies was found about specific aspects of intensive or
critical obstetric care. Research on for example hypertensive problems and pregnancy,
cardiac disease and pregnancy, haemorrhage, etc. were omnipresent. All of these
articles addressed certain aspects of (possible) life-threatening situations in relation to
maternal-foetal morbidity. Most of these studies were literature reviews with levels of
evidence between 3 and 4, very little systemic reviews or randomised controlled studies
were found.
Few articles studied, investigated the functioning of maternal intermediate care and the
organisational aspects of the associated hospital ward in depth. We identified 171
eligible articles of which 13 relevant MIC articles of relatively good quality were selected
(used critical appraisal tool: Checklist for observational studies, AHRQ). Almost every
study focused on a tertiary centre based retrospective analysis of hospital records of
parturients admitted to the (obstetrical) ICU or, in a few articles, to the high
dependency unit. These studies explored the individual tertiary settings and findings can
not be generalized because of the limited number of patients and the randomly selected
criteria for admission. Nearly all evidence regarding maternal intermediate care was
indirect evidence through ICU literature.
Moreover, the available literature did not provide evidence-based indications for
women who require a level of maternal intermediate care. Due to the lack of evidence
and utilizable criteria, a list of indications (based on expert opinion) leading to
intermediate care was created specially for this study.
Similar to the definition of maternal intermediate care, an evidence-based model of
admission criteria doesn’t exist. In the underneath listing we present a summary of
admission criteria internationally widely used. (Pre)eclampsia and haemorrhage are the
two commonest mentioned reasons for admission within the reviewed literature. The
underneath list complications is a brief synthesis and is not exhaustive.
Direct obstetrical complications 47 : pre-eclampsia, HELLP, severe haemorrhage,
trombo-embolic disorders, sepsis, placental abruption/praevia, inevitable premature
labour (before 32 weeks), premature rupture of the membranes (before 32 weeks),
intra uterine growth retardation (on vascular basis), congenital malformation wherefore
early treatment is recommended, multiple pregnancy (more than 2 neonates or
threatening premature birth before 34 weeks), …
47 The distinction between direct and indirect obstetrical causes of admission in MIC unit is proposed by
many authors (Waterstone, Bewley & Wolfe, 2001; Ancel et al, 1998; Panchal, Arria & Harris, 2000;
Murphy & Charlett, 2002; Dao et al, 2003; Koeberlé et al, 2000; Geller et al, 2002; Mirghani et al, 2004;
Oettle et al, 2004 and Mantel et al, 1998) Direct obstetrical complication are those resulting from
previous existing disease or disease that developed during pregnancy and that was not due to direct
obstetric cause but was aggravated by the physiological effects of pregnancy (ICD-10).Indirect obstetrical
causes are obstetrical complications resulting from previous existing disease or disease developed during
pregnancy which was not due to direct obstetrical causes but which was aggravated by the physiological
effects of pregnancy.